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Good Monday Morning
Discussion Board chat for the week:
Please post some take home points with specific patient/clinic applicability from last weeks’: Art and Science in Sports Medicine Conference.
Cheers
Eric
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Tim Uhl’s shoulder rehab and EMG presentation was very helpful for me! I have a couple of patients right now that this is incredibly helpful for considering progression (and regression) as necessary. I had never really thought to consider lever arm when performing scapular strengthening (physics was not my strong suit), but I thought the way he broke down progressions regarding load and lever arm was very helpful and made a lot of sense.
I was also encouraged by how much consensus there was between surgeons and PTs regarding SLAP repairs. I had a patient a month or so ago, who was considering getting his repaired and he ended up not undergoing surgical intervention due to his positive outcomes in therapy. His surgeon here in Woodstock was pushing the surgical route more than I thought was necessary, and it was nice to hear the opinions this weekend regarding surgical repair of SLAP tears.
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I really enjoyed Tim Uhl’s review of shoulder exercises with EMG findings as well. One great point he made when considering progression of a patient post Rotator cuff repair – Don’t underestimate the weight of the arm as a contribution to torque as it can make a very big difference in the difficulty of elevating the arm. As Katie said, short lever arm with elbows bent can be considered for many variations of elevation.
Tim also cited a 2017 JOSPT study by Edwards that lays out a nice chart of typical Shoulder rehab exercises and progressions based on EMG activity. -
Thigpen made a couple of really good points that stuck with me. He emphasized that he tries to stick with a consistent progression for athletes rehabbing their shoulder, for example. With a healthy athlete we may have a tendency to skip some of the more basic exercises. He tries to start them in the same place, but move through simpler exercises(eg in supine) more quickly for those who can – his point being that you can be more consistent and make sure that athletes are not missing the key components of a movement pattern.
I also like his idea of using a type of RPE(rate of perceived exertion) scale to help determine appropriate progression of strengthening exercises. For example – if an athlete finishes your whole session and rates his RPE at 3-4, they probably need to be pushed a little more.
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One take away from the lab portion – the importance of taking objective measures/assessing from the same position every time to improve accuracy. I remember Jake Magel stressing this as well. For example, if you assess ER PROM supine with the patient’s elbow supported on your leg – then that’s how you want to re-assess it post manual, or next visit, etc.
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Justin,
I loved the RPE for exercises too! I use that all the time with my patients, although I usually just ask “is this easy, medium or hard?” and go from there. I think I should be better about asking how the session as a whole was though instead of individual exercises. -
Since I was only able to make the Thursday portion due to another course Friday, It is helpful to hear some of the pearls you guys though were helpful from Friday and plan to look over the handouts! I thought the presentations were interesting regarding how difficult it can be for surgeons when deciding on appropriate patients for surgery (esp with the hip and shoulder labrum) and really saw this as another way PTs can work with physicians and the patients to make the best decision for each patient. Another big takeaway from Thursday was the importance of connecting with your patient, as it’s not always what you know, but how you relate that to the patient for both buy-in and understanding. I think this is something that takes a lot of practice and is so variable person to person. As VOMPTI has taught us, the subjective portion of the exam is vital to understanding your patient and setting meaningful goals.
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Echoing both Katie and Justin, I think that I will begin to use RPE more to judge the intensity of sessions as a whole rather than just asking how difficult individual exercises are. One of the more clinically relevant lectures for me at this juncture was Tim Uhl’s talk on exercise progressions for patients with rotator cuff pathology. In some of my patients s/p cuff repair, I probably initiate pulleys with them too early in the rehab process after seeing how much muscle activation actually occurs with pulleys. I will likely spend more time on supine exercises before progressing to exercises against gravity.
I also found it particularly interesting that the painful arc of shoulder motion that we use as a part of a diagnostic cluster for sub acromial impingement is not actually due to the tendon being compressed under the acromion, because the tendon does not get compressed above 60-70 degrees of abduction. When I treat patients with a painful arc, it will definitely change the way I use that information, leading me more towards tendon overload in that position rather than a mechanical compression.
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Along with everyone else I thought it was very helpful to see the EMG presentation with the stage by stage break down of appropriate exercises as to not stress the repairing tissue too much. I also thought it was very interesting to see the break down of impingement and how the tendon is actually cleared by the time out special tests would pick this up. It suggested it was tendon overload at these significant overhead motions which will absolutely change the way I think about the mechanics of the shoulder. Another great point that all of the presenters seemed to agree with was the lack of evidence supporting surgical repair of a slap tear and their prognosis. I am a firm believer in trying conservative methods first and some patients want the quick fix. This information is a great way to present the evidence in a way that may help patient buy in. In lab it was nice to see the three instructors different opinions on shoulder screening and special tests however, I was slowed down a bit and we were given more time to practice because the information given was valuable. Over all great weekend!
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